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Based on observation, interview, and record review, the facility failed to ensure

Based on observation, interview, and record review the facility failed to :

a. uphold the patients' right to execute an informed consent : a psychoactive medication as administered without a consent ( Patient ID # 4)


b. consents for psychoactive medications were accurately and fully completed for 6 of 12 sampled patients ( Patients ID: 2,3,4,5,6,12) :

Findings included:

a. Psychoactive medication administered without consent:

Record review of facility policy titled "Psychoactive Medication Administration Consent-Texas," revised date 02/01/2021, showed :"...the initiation or continuation of any psychotropic medication prescribed at admission or during the hospital stay requires a signed informed psychotropic medication consent form [facility bolding] regardless if the patient was admitted as voluntary or involuntary..."

Observation on 5/24/2023 at 9:30 AM showed Staff D, LVN administering medications to the patients in the common area. Staff-D administered gabapentin to Patient ID # 4.

Record review of the clinical record of Patient ID # 4 failed to show a documented informed consent for the medication gabapentin. Staff-B, Chief Nursing Officer, verified there was no consent and said this medication required a consent.

b. Consents for psychoactive medications not accurately and fully completed :

Findings included:

Record review on 5/24/2023 and 5/25/2023 of twelve (12) sampled patient records showed multiple "Education Acknowledgement & Consent to Treatment with Psychotropic Medication(s)" forms that were not accurately completed.

Review of each of the psychotropic medication consent forms listed below lacked a patient signature. If it was a verbal consent : there was no documentation of the name of person who gave the verbal consent.

Each of the consent forms listed below showed the same issue: above the line for "Patient's Signature": the following was handwritten : "consent obtained ." There was no documentation of who actually provided this consent .

Patient ID # 2: pscyhotropic medication consent for Effexor: "consent obtained"

Patent ID # 3 : pscyhotropic medication consents for Zoloft, Respiridone, Trazadone, Zyprexa, and Aricept: "consent obtained"

Patient ID # 4 : pscyhotropic medication consents for Cymbalta, Zyprexa: "consent obtained"

Patent ID # 5 : pscyhotropic medication consents for Zoloft, Seroquel: "consent obtained"

Patient ID # 6: pscyhotropic medication consents for Seroquel, Depakote Sprinkles, Haldol, Risperdal : "consent obtained"

Patient ID # 12: pscyhotropic medication consents for Namenda, Zyprexa, Depakote Sprinkles, Abilify, Seroquel, Trazadone : "consent obtained"

During on interview on 5/25/2023 at 1:15 PM with Staff-B, Chief Nursing Officer (CNO) she stated that writing "consent obtained" alone in place of a signature was not acceptable. She said if a verbal consent was obtained -the name of the person should be documented . If it was the patient who gave the verbal consent , it should indicate this, as well as the reason why the patient was unable to sign the consent.